Uric Acid Levels, Number of Standard Modifiable Cardiovascular Risk Factors, and Prognosis in Patients With Coronary Artery Disease: A Large Cohort Study in Asia

The impact of serum uric acid on biological aging and mortality risk: insights from the NHANES and CHARLS cohorts

Background

Serum uric acid (SUA), a byproduct of purine metabolism, exerts both antioxidant and pro-inflammatory effects, making its role in aging and chronic diseases a subject of ongoing debate. Despite this, the mechanisms by which SUA influences the aging process remain poorly understood.

Methods

We analyzed data from the NHANES (1999-2010) and CHARLS (2011-2015) cohorts to investigate SUA's impact on biological aging. Generalized linear regression models assessed SUA's effect on biological aging markers [ΔKDM-BA, ΔPhenoAge, and allostatic load (AL)], while Cox regression models estimated its association with all-cause and premature mortality. Dose-response relationships between SUA levels and aging markers (ΔKDM-BA, ΔPhenoAge, and AL), as well as all-cause and premature mortality, were evaluated using restricted cubic splines (RCS).

Results

In both cohorts, elevated SUA levels were significantly associated with accelerated aging. In the NHANES cohort, for each 1 mg/dL increase in SUA, ΔKDM-BA increased by 0.52 years (95% CI: 0.43-0.61, p < 0.0001), and AL increased by 0.38 (95% CI: 0.29-0.47, p < 0.0001). In the CHARLS cohort, SUA was similarly linked to an increase in ΔKDM-BA by 0.65 years (95% CI: 0.57-0.74, p < 0.0001) and AL by 0.15 (95% CI: 0.12-0.18, p < 0.0001). RCS analysis revealed a nonlinear association between SUA and ΔKDM-BA in NHANES, with a more pronounced acceleration of aging when SUA levels exceeded 4.16 mg/dL (nonlinear p < 0.0001). In CHARLS, SUA showed a nonlinear relationship with ΔKDM-BA (nonlinear p = 0.01). Additionally, in NHANES, SUA levels were associated with increased all-cause (HR: 1.04, 95% CI: 1.01-1.07, p = 0.01) and premature mortality (HR: 1.06, 95% CI: 1.00-1.13, p = 0.046). RCS analysis further demonstrated a U-shaped nonlinear relationship between SUA levels and both all-cause and premature mortality. In contrast, SUA did not show a significant association with mortality outcomes in the CHARLS cohort.

Conclusion

Elevated SUA is associated with accelerated biological aging in both U.S. and Chinese populations, but its link to mortality was evident only in the NHANES cohort. These findings highlight SUA as a potential aging marker and call for further population-specific investigation.

Predictive value of TG/HDL-C and GFR-adjusted uric acid levels on cardiovascular mortality: the URRAH study

BACKGROUND

Insulin resistance (IR) and serum uric acid (SUA) are closely interconnected: SUA contributes to adversely affects the insulin signaling pathway and contributes to IR, while IR is a known predictor for the development of hyperuricemia. The triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio has been proposed as an easily obtainable marker for IR. This research aimed to investigate the interaction between IR and glomerular filtration rate (GFR)-adjusted uricemia (SUA/GFR ratio) in determining CV risk in a large population cohort study.

METHODS

Data from 18,694 subjects were analyzed from Uric acid Right foR heArt Healt (URRAH) database. The study evaluated the association between TG/HDL-C ratio and SUA/GFR ratio, as well as their impact on the development of outcomes during the follow-up study period. The primary endpoint was CV mortality.

RESULTS

After a mean follow-up of 124 ± 64 months, 2,665 (14.2%) CV deaths occurred. The incidence of fatal and non-fatal CV events increased in parallel with the increase of TG/HDL-C quintiles. TG/HDL-C ratio showed a positive association with increasing of SUA/GFR ratio, even in non-diabetic patients. Multivariate analysis showed that the TG/HDL-C ratio increases the mortality risk even after adjustment for potential confounding factors. Finally, IR and GFR-adjusted hyperuricemia showed an additive effect on CV mortality.

CONCLUSIONS

Both IR and SUA/GFR ratio independently predict CV mortality, regardless of age, gender, BMI, diabetes, hypertension and statin use. The joint effect of the TG/HDL-C ratio and the elevated SUA/GFR ratio was greater than the presence of each single risk factor on CV mortality. This highlights the importance of monitoring these markers to better assess cardiovascular risk.

Gender differences in the prognostic impact of uric acid in patients with heart failure and preserved ejection fraction

BACKGROUND

Uric acid has been identified as an independent predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). However, the impact of gender differences on this association is not fully explored.

METHODS

This retrospective cohort study included hospitalized patients with HFpEF from June 2018 to October 2022. The primary outcome was a composite endpoint, defined as the occurrence of all-cause mortality and heart failure readmission. Kaplan-Meier survival analysis and stratified Cox regression examined the combined effect of gender and uric acid on the composite endpoint, and restricted cubic spline curves were applied to visualize the relationship.

RESULTS

The study included 547 patients, with 267 females and 280 males. In the entire cohort, each mg/dL increase in uric acid was associated with a 4% increase in the risk of the composite endpoint (HR: 1.04, 95%CI:1.01-1.09). This association was more pronounced in females, with a 9% increase in the risk of the composite endpoint per mg/dL increase in uric acid (95%CI: 1.02-1.17). Restrict cubic spline curves analysis demonstrated a significant linear correlation between increasing uric acid levels and higher risk of the composite endpoint in female patients (P = 0.028). Kaplan-Meier analysis revealed higher survival probabilities for females compared to males (P = 0.002). However, survival rates for females with high uric acid levels were similar to those for males with high uric acid levels.

CONCLUSIONS

Baseline serum uric acid levels are significantly associated with the composite endpoint in patients with HFpEF, particularly among females.

Validation of the role of apolipoproteins in coronary artery disease patients with impaired kidney function for prognosis: a prospective cohort study in China

OBJECTIVE

This study aims to evaluate the relationship between apolipoproteins (ApoA1, ApoB, and the ApoB/A1 ratio) and the incidence of major adverse cardiovascular events (MACE) in patients with coronary artery disease (CAD) and impaired kidney function, assessing their potential role in secondary prevention.

METHOD

A prospective cohort of 1,640 patients with impaired kidney function who underwent percutaneous coronary intervention in China was analyzed. Patients were categorized based on the measurements of ApoA1, ApoB, and ApoB/A1 ratio. MACE, defined as a composite of all-cause mortality, cardiovascular death, nonfatal myocardial infarctions, strokes, and unplanned revascularizations, was tracked post-procedure, with statistical analyses including Kaplan-Meier survival curves and Cox regression models to identify associations with apolipoproteins. Subgroup analyses according to kidney function were conducted.

RESULT

During a median follow-up of 3.1 years, 324 MACE events were observed. Multivariable Cox regression analyses illustrated higher levels of ApoB and the ApoB/A1 ratio were significantly associated with increased MACE incidence (adjusted HR [95%CI] 1.668[1.044-2.666]; adjusted HR [95%CI] 2.231[1.409-3.533], respectively), while lower ApoA1 levels correlated with a higher risk (adjusted HR [95%CI] 0.505[0.326-0.782]). ROC curve analyses indicated comparable predictive performances to traditional risk factors like LDL cholesterol. Subgroup analysis revealed that the above association was not statistically significant in the moderate-to-severe renal impairment CAD patients (eGFR < 45 mL/min/1.73 m2).

CONCLUSION

Our findings illustrate that apolipoproteins, specifically ApoA1 and ApoB, along with their ratio, are significant predictors of major adverse cardiovascular events in CAD patients with impaired kidney function. These results emphasize the need for incorporating apolipoprotein measurements in secondary prevention strategies for this high-risk population.

Elevated uric acid to serum albumin ratio: a predictor of short-term outcomes in Chinese heart failure patients

Background

The prognostic value of the uric acid to albumin ratio (UAR) in heart failure (HF) remains underexplored. The objective of this research was to investigate the link between UAR and short-term outcomes in Chinese HF patients.

Methods

We analyzed data from 1893 HF patients, out of an initial cohort of 2008, who had available UAR measurements. The skewed distribution of UAR data was addressed by applying a Log-10 (lg) transformation and stratifying patients into three groups accordingly (low to high). The final outcome was identified as mortality or hospital readmission within 28 days. We employed restricted cubic spline analysis (RCS), Kaplan-Meier survival curves, and Cox proportional hazards models to evaluate the link between UAR and short-term outcomes.

Results

Among 1893 patients with HF [≥ 70 years, 1,382 (73.0%); female, 1,100 (58.1%)], the incidence of 28-day outcome was 8.6%. The RCS analysis suggested a positive relationship between lg(UAR) and 28-day outcomes, with no evidence of nonlinearity (p = 0.008). The cumulative incidence of 28-day readmission/death indicated that patients in the tertile 3 faced a significantly elevated risk of adverse outcomes (p < 0.001). Cox proportional hazards models showed that an elevated UAR was associated with a greater likelihood of 28-day mortality or hospital readmission (HR = 2.433, 95% CI: 1.638-3.615, p < 0.001). Even after accounting for possible confounding variables, the result still existed (HR = 1.594, 95% CI: 1.032-2.462, p = 0.036). Moreover, the associations were consistent in various subgroups, and sensitivity analysis (all p > 0.05).

Conclusion

Increased UAR correlates with a heightened risk of short-term death or hospital readmission in Chinese individuals suffering from HF. Maintaining a relatively lower UAR could potentially improve the clinical prognosis for these patients.

Asymptomatic hyperuricemia: to treat or not a threat? A clinical and evidence-based approach to the management of hyperuricemia in the context of cardiovascular diseases

Asymptomatic hyperuricemia is defined by serum uric acid levels above 6.2 mg/dl in women and 7 mg/dl in men. In the presence of monosodium urate crystal formation and articular inflammation, hyperuricemia may become symptomatic (namely nephrolithiasis and gout). Uric acid results from purine catabolism and is at the centre of a complex metabolic interplay that involves oxidative stress, inflammation, renin-angiotensin-aldosterone system (RAAS) activation and insulin resistance. Uric acid levels present a continuous relation with conditions like hypertension and chronic kidney disease (CKD) and are reported to have an impact on risk of cardiovascular events. However, whether elevated uric acid is a causal agent and thus a possible therapeutic target is still uncertain and matter of further investigation. Treating symptomatic hyperuricemia involves lowering uric acid drugs and controlling inflammation. Urate-lowering agents are well tolerated but show minimal impact on cardiovascular events in patients with gout. Use of direct-acting urate-lowering agents in asymptomatic hyperuricemia associated with cardiovascular diseases does not warrant a clear benefit, whereas addressing cardiovascular issues with guideline-recommended therapies lowers uric acid and reduces the occurrence of cardiovascular events. Regular assessment of uric acid and clinical symptoms is advised before starting and renewing a urate-lowering treatment.

A high level of uric acid is associated with long-term adverse cardiovascular outcomes in patients who received fractional flow reserve with coronary intermediate stenosis

BACKGROUND AND AIMS

The role of fractional flow reserve (FFR) in coronary intermediate lesions is widely recommended by guidelines. The effect of uric acid (UA) on cardiovascular events is also well known. However, the relationship between UA and long-term cardiovascular outcomes in patients who received FFR with intermediate lesions remains unknown.

METHODS AND RESULTS

We retrospectively included 428 patients who underwent both coronary angiography (CAG) and FFR. Participants were stratified into two groups based on the median UA. The primary endpoint was the composite of major adverse cardiovascular and cerebrovascular events (MACCEs), including repeat revascularization, nonfatal stroke, nonfatal myocardial infarction, and all-cause death. A Cox proportional hazards model was utilized to analyze the association between UA and the prevalence of MACCEs. During a median follow-up of 5.8 years, a higher MACCEs rate occurred in the high UA group compared to the low UA group (16.8% vs. 5.1%, p log-rank<0.01). Elevated UA was independently linked to a higher incidence of MACCEs, whether UA was treated as a categorical or continuous variable (hazard ratio [HR] 2.76, 95% confidence interval [CI] 1.27-6.03 or HR 1.01, 95% CI 1.01-1.02). The restricted cubic spline (RCS) analysis illustrated that the HR for MACCEs increased with increasing UA.

CONCLUSION

The present study demonstrates that UA is associated with MACCEs risk and suggests that UA is a reliable predictor of long-term cardiovascular events in coronary intermediate stenosis patients.

Association of Serum Uric Acid with Non-Valvular Atrial Fibrillation: A Retrospective Study in China

Purpose

The association between serum uric acid (SUA) and atrial fibrillation (AF) has been widely focused on and studied in recent years. However, the exact association between SUA and AF is unclear, and the effect of gender on the association between SUA levels and AF has been controversial. This study aimed to investigate the association between SUA levels and non-valvular AF (NVAF) and the potential effect of gender on it.

Patients and Methods

A total of 866 NVAF patients (463 males, age 69.44 ± 8.07 years) and 646 sex-matched control patients in sinus rhythm, with no history of arrhythmia were included in this study. t-test, ANOVA, and chi-square test were used for baseline data analysis. The receiver operating characteristic curve, logistic regression and Pearson correlation analysis were used for correlation analysis.

Results

Compared to controls, NVAF patients exhibited higher SUA (P<0.001). After adjusting for confounders of NVAF, SUA remained significantly associated with NVAF, regardless of gender (OR= 1.31, 95% CI 1.18-1.43, P<0.001). SUA demonstrated higher predictability and sensitivity in predicting the occurrence of female NVAF compared to male (area under the curve was 0.68 (95% CI 0.64-0.72, P<0.001), sensitivity 87.3%), with the optimal cut-off point identified as 5.72 mg/dL. Furthermore, SUA levels correlated with APOA1, Scr and NT-proBNP in NVAF patients. SUA levels varied significantly among NVAF subtypes.

Conclusion

High SUA levels were independently associated with NVAF, regardless of gender. SUA exhibited higher predictability and sensitivity in predicting the occurrence of NVAF in females compared to males. High SUA levels may affect other NVAF-related factors and participate in the pathophysiological process of NVAF.